Background: In Japan, although parents would like their children to be able to obtain medical care from a pediatrician regardless of the time of day, it is important that emergency physicians (EP) actively participate in the medical care of children to guarantee access to medical services for all pediatric emergency patients. We evaluate the quality of medical care given by EP to pediatric patients in one emergency department (ED).
Method: We analyzed pediatric patients who were discharged from the ED of a single hospital in Japan during long-term consecutive holidays and who revisited the ED within twenty-four hours. Demographic data, the chief complaint, diagnosis, and disposition following the second ED visit were recorded. We investigated whether pediatric patients who did not revisit the ED were admitted to acute care settings of other hospitals.
Results: During the study period, 661 pediatric patients visited the ED, and 626 patients were discharged and allowed to go home. Thirteen percent of the discharged patients (79/626) revisited the ED within twenty-four hours after their first ED visit. Although additional medical care was not needed at the second visit in seventy-five percent (59/79) of these patients, five patients (6.3%) were admitted to acute care settings. Of the 5 patients admitted, three were advised to be admitted and two were thought to be stable enough to be discharged on their initial visits. The initial evaluations of the two patients who were discharged, which accounted for 0.3% of the total patients, were thought to be insufficient. Eighty-one percent of the reasons given by parents for taking their child back to the ED was their anxiety about their child's prolonged symptoms. None of the patients who were discharged from the ED at their first visits were admitted to acute care settings of other hospitals.
Conclusions: EP were found in most cases to give appropriate medical care to pediatric patients in this study. It is essential to enlighten the public about how effective EP are in giving medical care to pediatric patients. Even when additional medical care is unnecessary, many pediatric patients revisit the ED because of their parents' anxiety about prolonged symptoms. This suggests a need on the part of EP to explain the natural course of the disease and the specific symptoms to watch out for and also to address the anxiety of the guardians on the initial visit.

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We observed the larynx in inhalation injury by serial fiberoptic bronchoscopy (FOB) to establish intubation criteria based on laryngeal edema. Between November 1991 and April 1997, 156 patients were admitted to our hospital due to burn and or inhalation injury. Sixty-eight patients who underwent FOB within 24 hours after injury had evidence of laryngeal injury. Endotracheal intubation was performed according to pre-determined criteria. Patients with laryngeal injury were assigned to one of five groups based on whether they were intubated or not, the timing of intubation, and the reason for intubation. Group I (n=14) patients had marked laryngeal edema and were intubated after initial FOB according to the criteria. Group II (n=14) patients did not have severe laryngeal edema but were intubated after initial FOB according to the criteria. Group III (n=4) patients were not intubated after initial FOB but were intubated after follow up FOB according to the criteria. Group IV (n=33) patients were never intubated according to the criteria. Group V (n=3) patients were intubated after initial FOB based on the attending physician's decision. Pre-established intubation criteria were not met in this group. 1) We examined the relationship between laryngeal edema and post injury interval in group I, III, and IV. 2) We examined the relationship between groups I, II, III, and IV and age, total burn surface area, burn index, prognostic burn index, presence of facial burn, and presence of cervical burn. 3) We examined the relationship between group III, IV and serum total protein level and treatments that might influence laryngeal edema. Results; 1) Using our intubation criteria, enodtracheal intubation was not required in 48.5% of patients. Our intubation criteria provide an evidenced based strategy for preventive intubation. 2) Biphasic peaks of laryngeal edema were recognized within 24 ours after injury. 3) In addition to direct injury, body burn is a significant factor for progressive laryngeal edema.

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We reported a patient with intestinal tuberculosis with hemorrhagic shock. A 62-year-old woman was admitted to a regional hospital for the introduction of hemodialysis, and was diagnosed with Crohn's disease based on the findings of a barium enema, colonoscopy and pathological examination. She was managed with steroids. She was admitted to the hospital again and presented a low grade fever, and was treated with steroids and immunosuppressive drugs without improvement. She fell into shock with anal bleeding and respiratory distress. After the administration of catecholamine, she was transferred to our center. Although we did not think she was exhibiting Crohn's disease, we have to perform an immediate operation (right colectomy) because of the comments of the pathologist at the previous hospital and her shock. The patient did not recover from refractory septic shock and died on the 6th day. We determined that the correct diagnosis of the patient was active intestinal tuberculosis on the basis of a pathological examination of the resected specimen after the patient died. Managing patients with Crohn's disease treated with steroid, we should always consider differential diagnosis from intestinal tuberculosis. In the emergency departments dealing with patients without sufficient informations, careful check should be recommended in annual routine medical examination for staffs exposing patients who revealed tuberculosis after treatment.

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A 79-year-old woman was transferred to an emergency care center because of difficulty opening her mouth. Major trauma was not evident but she had a scab from a minor injury on the right fifth finger. Three days later, sudden respiratory failure and heart failure developed with an inverted T wave in electrocardiogram, Takotsubo-like wall motion and slightly elevated creatine kinase and troponin T. We isolated Clostridium tetani from the scab on her finger and from soil at the farm where she worked. Tetanus was clinically and biologically diagnosed and she was sedated, ventilated and given circulatory support. She was discharged on hospital day 35. Isolation of C. tetani is very rare and to our knowledge, this is the first time that C. tetani has been isolated from a scab. C. tetani infection cannot be discounted even when a wound is in a stage of advanced healing and such wounds should always be debrided for therapeutic purposes.

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We report the results of surgical treatment for spontaneous esophageal rupture performed in one medical center.
Methods: We examined 9 cases of spontaneous esophageal rupture from 1991 to 2007. There were 8 male patients and 1 female patient, and the mean age of the group was 65. For each case, we identified the kind of operation performed, any complications, and whether the patient survived.
Results: Patients received a wide variety of surgical treatments. Four patients were treated with direct closure, 1 patient with fundic patch, 1 with T-tube drainage, 1 with diaphragm patch, 1 with esophagectomy and esophageal fistula, and 1 with drainage. There were 6 cases of leakage (66%) and 2 deaths (22.2%).
Discussion & Conclusion: The mortality rate at this center was similar to the national rate (18%). Although patch operations such as fundic patch and intercostal muscle patch have come into use recently, direct suture is still the main treatment for spontaneous esophageal rupture at this center. The leakage rate in this operation was high, but precise drainage improved the morbidity rate. The leakage rate can probably be improved by peeling off as little of the tissue surrounding the esophagus as possible.

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A 60-year-old male patient with tube feeding, suffering from quadriplegia by a high spinal cord injury, had changed to a gastrostomy catheter button. Two weeks later he had to be admitted to our critical care center, for support for developed anemia, melena, vomiting, and abdominal distention. The gastroduodenoscopy on admission revealed a gastric linear ulcer just under the cardia, and so we diagnosed it as Mallory-Weiss syndrome (M-W synd). However we could not see abdominal distention and discover the reason for it. On hospital day 5, via a second gastroduodenoscopy, we could see that a migration of the balloon had caused a pyloric obstruction, resulting in the distension of the epigatrium. It is uncommon for the migration of balloons to gives pyloric obstruction in a patient with a gastrostomy catheter button. Furthermore, it is unique that a pyloric obstruction causes M-W synd. Medical physicians should be careful about the possibility of a pyloric obstruction causing M-W synd.

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